Provider Demographics
NPI:1245413715
Name:MED-SOUTH PRIMARY CARE
Entity Type:Organization
Organization Name:MED-SOUTH PRIMARY CARE
Other - Org Name:MED-SOUTH PRIMARY CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PADGETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-506-0100
Mailing Address - Street 1:1240 EAGLES LANDING PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281
Mailing Address - Country:US
Mailing Address - Phone:770-506-0100
Mailing Address - Fax:770-507-2597
Practice Address - Street 1:1240 EAGLES LANDING PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:770-506-0100
Practice Address - Fax:770-507-2597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047830207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00932357AMedicaid
GA11BDVGJMedicare PIN
GA00932357AMedicaid